89 year old female with PMB and bilateral pelvic masses.

Distant patient (Armidale), with proposed procedure – laparoscopy, BSO, D + C, cone biopsy or LLETZ +/- mirena insertion.

Background

1. AF on warfarin
2. CCF – managed medically, PRN frusemide. Low normal systolic function on most recent Echo.
3. CVA – 2012 with only remaining effect of impaired balance requiring walking stick.
4. HTN
5. Severe OSA – on CPAP with good compliance
6. Severe pulmonary hypertension on Echo cardiogram (2/21) Estimated PASP – 65mmHg.

Issues

• Phone consultation – patient requesting due to difficulty of transport and travel. Long conversation, including trends in weather and climate!
• Patient very involved in decision making around health care. At this stage uncertain about optimal management and location. Considering less invasive options at hospital in Armidale (i.e D and C/Mirena) vs travel to Newcastle for larger laparoscopy. Has even consulted her old GP for advice, who she felt had similar values to her own! All her local friends also have opinions to consider!
• Higher risk patient – NSQIP risk score – mortality 1.8%, serious morbidity 13%, discharge to location other than home 22%. Although DASI by phone was 4.6 METS.

Discussion

• Difficulty of phone consultation for ‘tricky’ patients. The triage criteria for phone vs face-to-face appointments was discussed. At this stage major surgery (LOS> 1day) was the baseline consideration for face to face. However the Preoperative clinic is taking feedback on other groups of patients who it is felt were better suited to face to face appointments. Note that there is currently Medicare funding for telehealth consultations until Dec 2021. Although it seems unlikely that a post-pandemic world will return to all face to face appointments!
• Invasive vs non-invasive treatment options for surgery. Patient was having ongoing consideration of treatment. At this stage she is planned for D and C on day of surgery in Newcastle.